With the issue of mandatory vaccination programs for infants and children, lines have been drawn in the sand. On one side, we find concerned parents, increasingly being supported by dissenting physicians and scientists troubled by the serious side effects of vaccines, which have, in fact, been reported with greater frequency, including serious neurological deficits and even death. Physicians on this side of the line have not only asked for more open data and information to the public, but question the statistics as it regards specifically risks versus benefit studies, the need for adhering to the individual-based ethics and admonition of Hippocrates of first doing no harm, and allowance for more parental involvement and freedom of choice — that is, the right of parents to refuse to give their children certain vaccines; and full informed consent for parents — that is, complete disclosure of all pertinent information relating to vaccine safety and efficacy.

On the other side of the line, we find government bureaucrats, public health officials, central planners, and much of the organized medical establishment militating for a greater role of government in “developing immunization strategies,” developing tracking databases, increasing medical surveillance, and accelerating the pace of vaccine development, as well as enlarging the scope of mandatory vaccine programs already in place, particularly for infants and pre-school children. This group is bolstered not only by the coercive power and financial coffers of the federal government but also by the new collectivist, utilitarian ethics of population-based medicine. Recently, this group has even invoked history and the past necessities of medical authorities for using a variety of public strategies which may at times infringe on individual liberty. On August 3, 1999, U.S. Surgeon General David Satcher reminded chairman Dan Burton (R-IN) and his House Government Reform Committee of the benefits of mass immunization in protecting society from such historical scourges as poliomyelitis, measles, tetanus, meningitis, and other pestilential diseases once dreaded by man. He reassured the committee that “serious side effects are rare and that the benefits of immunization more than outweigh any potential risks.” He added that vaccines are to be considered among the safest and most effective medicines in man’s armamentarium in the fight against diseases.

And so, with this introduction, perhaps we should take a retrospective look at the history of vaccination and touch upon the development of the germ theory of disease to which it’s necessarily entwined.

Smallpox, Conquests and Empires

The earliest history of the development of vaccines is inextricably linked to the story of the breakthrough against smallpox. In fact, the word vaccine is derived from vaccinia…But I’m getting ahead of myself. Let us start from the very beginning…

The prelude to the coming Age of Scientific Medicine was anticipated in the midst of the Age of Reason with the auspicious contribution of the English country physician, Edward Jenner (1749-1823). But the history of smallpox, which culminated with Dr. Jenner’s story and his immense contribution to mankind, did not begin with this gentle physician. There is ample historic evidence, in fact, that smallpox was most likely the epidemic that ravaged Rome in A.D. 166-167, the much debated pandemic which the great physician Galen has been erroneously accused of fleeing — in sake of personal safety.1-5 Lucius Verus, the co-emperor of Stoic philosopher Marcus Aurelius succumbed to this disease in A.D. 169. As a result, upon the death of Marcus Aurelius, the greatly successful adoptive system of imperial succession was abandoned, and inauspiciously, his brutal son Commodus became emperor in A.D. 180, setting up a series of imperial crises that ended a century later with the ascension to the throne of the dictatorial emperor Diocletian.

Smallpox was also one of the dreaded and deadly pestilences that arrived with Christopher Columbus (1451-1506) and the Conquistadors in the New World, wreaking havoc in the immunological susceptible native populations. It particularly struck with a vengeance on the heavily populated Empire of the Mexica (i.e., the Aztecs at Tenochtitlan, decimating millions of the native inhabitants of Mexico, and later, the rest of Mesoamerica). Smallpox facilitated the conquest of the mighty Aztecs in the year 1521 — by the intrepid Spaniard and Extremaduran adventurer, Hernan Cortés (1485-1547) — after two years of savage warfare. There is no doubt now that the smallpox and measles epidemic that assailed the Aztecs and other indigenous tribes contributed significantly to the epic conquest of Mexico by the Spanish Conquistadors.(6-10) [See insert below.]

Smallpox and the Conquest of the Aztecs

It took more than smallpox and other European maladies to subdue the Aztecs. The story of how an empire of millions of fierce warriors was conquered by a handful of determined Conquistadors is an historic incident of epic proportions. Besides smallpox and other epidemic diseases which did take its toll on the brave but human-sacrifice driven Aztecs, there was Cortés’ leadership, iron will, determination and resilience, imperviousness to danger — and his fortuitous and intriguing relationship with the captured Mayan princess, La Malinche, later christened Dona Marina, who not only interpreted and translated the Nahualt, the language of the Mexica, to Spanish for Cortés, but also provided needed geopolitical advise and covert reconnaissance (spying) work as Cortés’ trusted confidant and consort.

Despite astronomical odds against him and his would-be Conquistadors, Cortés pushed forward, bent on conquering the vast Aztec armies under the command of its powerful but indecisive emperor Moctezuma, the Uey-Tlatoáni or “Revered Speaker” of the Mexica. Cortés, knowing that he and his companions faced an immense army supported by an empire of millions, pushed onward (and to make sure that there were no deserters, he burned his own ships). They were in a strange land and would literally either die or conquer it. Then there was also the protection afforded them by the obscure legend of the returning Toltec god Quetzalcoatl, which troubled Moctezuma and befuddled Cortés. The return of the feared god Quetzalcoatl who was expected to reclaim his throne was facilitated by the bad omens haunting the Aztecs. For instance, they were horrified by the inauspicious observation of the fiery object in the sky, the return of Halley’s comet, which was then visible to the naked eye for all superstitious eyes to see.

All of these factors, including the 519 determined Spanish soldiers and their 16 horses, 12 canons, and the 30 muskets and crossbows that they carried were also important in the subjugation of the Aztecs. Lastly, there was the assistance rendered by their Indian allies, the Xempoalans initially, and later the more enduring and significant support of the Tlaxcalans. The latter virtually rescued the Spaniards from the jaws of defeat in their most urgent hour of need, during La Noche Triste, and afterwards, to the bitter end of the conquest. But that fateful and compelling story is for another time. The point is that smallpox did not do it alone, although it did play a significant role in the conquest of the empire of Mexica and the securing of a major foothold for the Conquistadors and the establishment of a New World for the Europeans.

Cowpox, Inoculation and Dr. Edward Jenner

Preventive inoculation of those vulnerable to smallpox (variola) with postular material from lesions of persons with mild cases of the disease (to deliberately contract a mild form of the illness), was known to cause immunity, as it was known to be practiced by the Chinese of the Sung Dynasty by 590 B.C., as well as by the Hindus in India by the 2nd and 3rd century A.D.(11)

The practice of inoculation was divulged in the West after its dissemination in England as a result of a letter by Lady Mary Wortley Montague, wife of the ambassador to Turkey in 1717, in which she accurately described the technique of variolation as practiced in Constantinople. She also described the clinical manifestations of the mild form of the disease that followed preventive inoculation. After learning of its benefit against a dreadful disease, the British Royal family underwent inoculation (variolation) and thereafter many other royal families in Europe adopted the practice.

In the United States different personalities entered the public debate on smallpox inoculation. Persons, as different as the stern Reverend Cotton Mather (1663-1728), the Puritan minister who wrote extensively about diabolical possession and witchcraft, and the witty American statesman, patriot and scientist, Benjamin Franklin (1706-1790), became involved in the controversy. Surprisingly, both of these contrasting personages became adherents of variolation and were strong proponents of smallpox inoculation. Even George Washington (1732-1799), the revered first President of the American Republic, joined the group of proponents of inoculation in an attempt to contain the spread of the dreaded disease. Yet, with variolation, despite some protection, some people still contracted the disease and died from it.

But not all the people accepted inoculation as God-sent. The Boston physician Zabdiel Boylston (1680-1766), who introduced the practice of inoculation to America, was almost lynched by a mob for this audacity. His effort was obviously not appreciated by everyone. It had been Rev. Mather who had persuaded Dr. Boylston to adopt the practice and had supported Boylston in his great effort in June 1721. Yet, despite the initial opposition, Dr. Boylston went on to be the first man in America to actually inoculate New Englanders against smallpox (Boston, June 26, 1721). In France, it was Voltaire who espoused and strongly militated for the practice of inoculation. He even convinced Catherine the Great (1729-1796), the Russian imperial family, and the members of court to follow suit with inoculation.

But Dr. Edward Jenner (1749-1823), the English country physician, deserves the largest share of the credit for widespread vaccination and eventual eradication of smallpox. He is one among those great medical giants who, almost single handedly, laid down a great foundation block in the construction of the ever-growing edifice of medical knowledge.

His discovery and his contribution were possible because, as it often happens in medical history, he made a valid and fateful observation. He noticed that farm and dairy workers were afflicted with cowpox which was very prevalent in dairy cattle. The cowpox sores (vaccinia) were very similar to those of smallpox (variola). Moreover, he noticed that those afflicted with cowpox would only have chills and malaise, for a day or two, and then quickly recovered without sequelae. Adding more pieces to the puzzle, he also observed that when smallpox broke out in the area, those who had been sick with the mild case of cowpox did not get the smallpox. Dr. Jenner correctly surmised that cowpox infection conveyed some type of immunity against smallpox. But he did not stop with these observations; he did something else: Following the scientific method, he pursued the trail of his observation with experimentation, and his results and data were carefully recorded and analyzed with mathematical precision. His findings were then submitted to the Royal Academy of London.

On May 14, 1796, Jenner inoculated his patient 8-year-old James Phipps with cowpox-infected material from a local milkmaid. The boy apparently had the expected mild form of the lesions and no serious illness was manifest. Several months later, Dr. Jenner again inoculated the boy, and this time he found that there was no effect at all. He had actually succeeded in vaccinating the boy. Vaccination was a reality. Yet, there is evidence he was not the first to think of this idea, that is, to use cowpox to inoculate against smallpox, but as Sir William Osler (1849-1919) wisely once said, “in science the credit goes not to the one who first thinks of the idea, but to the one who convinces the world.” After Jenner’s breakthrough with vaccinations, the world listened. In the United States, President Thomas Jefferson (1743-1826) espoused the concept of vaccination and strongly militated for its adoption. In France, Emperor Napoleon Bonaparte (1769-1821) was of the same opinion and acted accordingly — having his entire army vaccinated in 1805.(11)

The war against smallpox went on for nearly two centuries but the conquest of the dreaded disease was completed in 1974, when the disease was completely eradicated. It was a triumph of medical progress; it was a triumph of medicine. Dr. Jenner had paved the way for even greater advances, those of Louis Pasteur’s general immunization methods and the discovery and subsequent corroboration of the germ theory of disease, which in its wake, ushered in even greater advances of scientific medicine.

Anthrax, Rabies, and Dr. Louis Pasteur

The illustrious chemist Louis Pasteur (1822-1895) contributed enormously to the fields of chemistry, bacteriology, immunology and general medicine — although he was not a physician. His father was a tanner who served under Emperor Napoleon. Pasteur was born at Dôle, France and graduated in chemistry from the École Normale in Paris in 1847.

One of Pasteur’s first accomplishments was to rescue the one industry of France that was indispensable, the French wine industry, when it was threatened with imminent disaster — microbial fermentation and spoiling of the fine wines of France. He taught the vineyard peasants and wine workers a process whereby raising moderately the temperature of the wine, bacterial growth was thwarted, thus the beverage could be kept from spoiling. This feat alone, would have immortalized this great scientist, and the process by which he saved the wine industry from utter disaster became known as pasteurization.*

Next, he discovered the agent responsible for the disease that was devastating the silk industry in France. Silk caterpillars were dying. He demonstrated they were infected with a bacterium that produced disease and showed silk producers how to maintain healthy stocks, saving the industry (one of the largest in France at the time) in the process.(13)

Pasteur was an indefatigable worker. Despite suffering a stroke in 1865, from which he never fully recovered, his greatest achievements were yet to be realized. In 1877, he came, this time, to the rescue of the cattle and sheep industry assailed with anthrax, a disease that had been decimating thousands of the animals. To combat this malady and to protect the susceptible animals, he developed a method of vaccination (which he so named in honor of Dr. Edward Jenner, whose discoveries and their significance he was well aware). Here again his efforts paid off and with vaccination, he saved the cattle and sheep industry from the scourge of anthrax.(14)

Pasteur was very much interested in the phenomenon of immunity but he entered this field almost by chance while studying the poultry disease “chicken cholera.” A medical historian writes: “One evening, he inoculated a chicken with a culture made with the chicken cholera germs. By a chance that now seems almost miraculous, the culture was some six weeks old, and, to use a layman’s term, might have been called a ‘stale’ one. The fowl became ill, but not seriously so, and then it recovered completely. Using the same bird and a fresh culture of virulent microorganisms, Pasteur was fascinated to find that although the germs were highly dangerous to any uninoculated chicken, the treated bird appeared to have become resistant to the infection.”(15) He reasoned that the “stale” cultures were actually “attenuated” or less virulent microorganisms. With these attenuated organisms, Pasteur could induce an immunity or resistance to future infections. And he was correct. From here, his attention turned to sheep and cattle, which, as we have mentioned, he successfully inoculated against anthrax using the methodology he had developed for the chicken cholera virus.

He then made history in an open forum giving those of us who believe in “the use of open data and public review” in scientific research(16) a shot in the arm: “In this classic demonstration [at the farm Pouilly-le-Fort near Melun], Pasteur took three flocks of sheep. The first group, of ten sheep, was to act as the ‘control’ animals. The second flock, of 25 sheep, had previously been inoculated with an attenuated culture of live anthrax germs. The third flock — also of 25 sheep — had not. Then, before an audience of scientists, doctors and other interested parties, some of whom believed in the importance of what he was doing and some of whom did not, Pasteur injected all the animals save those in his control group with a virulent culture of anthrax germs. To the great satisfaction of his friends and sympathizers and to the equally great chagrin of his critics, all the uninoculated animals died, as he had said that they would, and all the inoculated ones remained alive.”(15)

With his new method of immunization in 1885 (when he was already 63 years old), Pasteur treated the 9-year-old shepherd boy Joseph Meister who had been savagely bitten 14 times by a rabid dog. French physicians had no treatment to offer him and the boy’s prognosis was grave. Aware of Jenner’s cowpox inoculation experiments, he devised a different method of immunization by reducing the virulence of the pathogenic organism and thereby inoculating the attenuated form of the virus to induce active immunity against the rabies virus. First, he used laboratory animals in his experiments and then, after his successful post-exposure vaccination treatment (which was possible because of the long incubation period of this virus), he treated his patient. The vaccination was successful and the boy’s life was saved.

Pasteur personally treated and saved many others with his series of immunization treatment, but he indirectly saved countless others with his immunization techniques, which have been used by physicians worldwide since that time. In fact, as a result of his immunization methods, rabies, though still a dreaded disease which carries an extremely high mortality, is no longer the threat to human life that it once was, prior to his discoveries.

Spontaneous Generation and the Germ Theory of Disease

It was also up to Louis Pasteur to establish in 1885 a clear relationship between microorganisms and disease, and formulate the fundamental principles of the germ theory of disease. The latter was the most outstanding breakthrough in biology and medicine since William Harvey’s discovery of the blood circulation (and Edward Jenner’s inoculation rationale for smallpox). Perhaps, most importantly, Pasteur also demolished, and finally put to rest, the old theory of spontaneous generation that had held medicine back for centuries. Instead, he convincingly demonstrated his theory that living microbes caused fermentation, putrefaction, and disease.

As we have seen, he developed vaccines to combat a variety of illnesses caused by microorganism; thereby, saving innumerable lives and advancing the human condition. It was Pasteur, whose systematized observations and experiments clearly rejected the theory of spontaneous generation and the conventional doctrine, which ascribed disease to miasmas from marshes rather than living microbes. In fact, it is from this erroneous doctrine that malaria (“bad air”) takes its name. Malaria, of course, we now know is caused by the protozoan parasite Plasmodium falciparum and transmitted via the Anopheles mosquito, and which, incidentally, is on the rise in Africa and parts of Asia because of the banning of the effective pesticide DDT.

The rejection of spontaneous generation and the doctrine of the miasmas as sources of disease were necessary steps for the advancement of science and the formulation of the scientific germ theory of disease. Pasteur was another rare individual, like Harvey, Jenner and Robert Koch, who almost single handedly, armed with genius and determination, added portentous building blocks of knowledge to the edifice of medical progress.

Along with the widespread use of clean, potable water; improved hygiene and sanitation; the better (higher) standard of living, heralded by the Industrial Revolution; the advent of the germ theory of disease with other advances of the 19th century, such as the development of anesthesia; and the unraveling of the DNA molecule in the 20th century — one must also include the development of vaccination in the 18th century with the conquest of smallpox (which was not to be completed until the 20th century), as among the towering achievements of the scientific era of medicine.

Immunization, Hippocrates and Medical Ethics

And it’s worth pointing out that these scientific achievements that benefited humanity were, nevertheless, based on their benefit to patients and within the purview of the traditional ethics of Hippocrates. Recall Drs. Jenner and Pasteur and their young patients, James Phipps and Joseph Meister. Recall although Pasteur was not a physician, he upheld the Hippocratic tradition of doing no harm and asking for appropriate consultations. He, in fact, obtained consultation with various physicians — ascertaining that there were no other treatments available — before rendering experimental treatment to his young patient.

It goes without saying, and we should interject here, that physicians who followed the Oath and ethics of Hippocrates must always satisfy two conditions: 1) The healers must place the patient’s interest above the cost considerations of third party payers or their own personal or monetary benefit, 2) physicians must place the interest of their individual patients above that of the collective, be that the health care networks, or some “greater good” of society or the state.

Unfortunately, recent mandatory vaccination programs have placed these two conditions in question. Some physicians have even questioned whether these mandatory public health policies subordinate the patient-doctor relationship to the manifest interest of the state.(17) In which case, the physician is no longer the advocate of his individual patients, but serves as the agent of the state. Rather than placing the interest of his patients first, he is coaxed or coerced to abdicate his responsibility to his patients for the purported “greater good” of society. This collectivist ethic is rooted in the new tenets of population-based medicine associated both with managed care and “national health” policies.

In this situation, the physician is placed in a great dilemma and he, in the Socratic tradition, nosce te ipsum, should ask himself: Am I recommending vaccination to my patient because it’s in her best interest, in her particular medical situation, or simply because I must comply with the state’s mandate for universal vaccination?

Although, in most cases, physicians would recommend immuni-zation (based on a risk-benefit estimate) for most patients, when making a specific determination — he must still consider the special situation of his patient first and uphold Hippocrates’ Oath: “I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”**

There is no question of the great benefit of general immunization for such mankind scourges as poliomyelitis, diphtheria, smallpox, etc.; but can we say the same for greatly self-limited rotavirus diarrhea and chickenpox for children, or for the sexually transmitted hepatitis B for infants?

And, in the case of rabies, we institute aggressive immunization treatment only after exposure. Public health should be geared to protect populations at risk from afflicted or in some cases, exposed individuals, not the opposite, as it seems today, as in the case with healthy children not allowed to enter school until complying with a variety of immunization protocols, or parents accused of being child abusers for the same reason.(18)

A Modest Proposal

Is it to his or her benefit for this newborn infant to be vaccinated against hepatitis B, for example, or could the youngster wait until he is older and stronger and when the risk of contracting hepatitis B may be more significant? And particularly so when we don’t know even how long immunity will last. And in the case of adults who prefer to abstain from risky behaviors that may lead to sexual herpes, hepatitis B, or HIV infection, why can they not exercise their freedom rather than being forced to be immunized against diseases they simply will not contract because of the method of transmission. Of course, some authorities, particularly in organized medicine, disagree with us that individuals and parents can make their own decisions, supposedly because of all the information “surfing the internet.”(19) Government wants to protect us from ourselves, and control entire populations from birth. Whereas historically, exposed or infected persons were quarantined to prevent spreading of a disease, today, it seems, the unimmunized person becomes the public health threat as in the aforementioned cases of hepatitis B and school children excluded from public schools, or the court-martialed soldiers in the case of the anthrax vaccine in the military.

Fortunately, the pages of medical history are replete with indisputable evidence, including the aforementioned stories of vaccination, that physicians, upholding the Oath and individual-based ethics of Hippocrates actually benefit not only their individual patients but also society, secondarily. In other words, physicians working in the enlightened best interest of their patients actually result in tangible benefits to humanity as a whole. On the other hand, the historic record also reveals, in this very century, when that is not the case and physicians become agents of the state rather than advocates of their patients, events go awry. They became preoccupied with preventive health measures and the so-called proper allocation of scarce resources, rather than the health of their individual patients, and medicine becomes subject to the subordination of the state with the result being as perverse as it was disastrous. Judge the results of socialized medicine behind the Iron Curtain, e.g., Rumania with destitute, sick and HIV-infected children in orphanages and Soviet Russia with its filthy operating rooms and sordid hospitals. Doctor, you choose and to thine own self be true.

In Part II, we will answer the question of whether a physician should abide by the Oath of Hippocrates or comply with population-based medicine on this issue of vaccination.

Footnotes

* For this and other accomplishments, he has also given his name to the prestigious Pasteur Institute in Paris where Dr. Luc Montagnier first isolated the HIV virus.(12)
** Another translation of this passage reads: “I will prescribe regimen for the good of my patients according to my ability and judgment and never do harm to anyone.”

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